Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach

Abstract

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.

Keywords: Damage control surgery; REBOA; aortic occlusion; hemodynamically unstable non-compressible penetrating torso trauma; median sternotomy.

Figure 1. Blood flow redistribution following REBOA placement in Zone 1

Figure 2. A. Median Sternotomy with Supra-clavicular Right or Left Extension; 2B. Median Sternotomy with Cervical Right or Left Extension

Figure 3. Antero-lateral Thoracotomy plus Clamshell

Figure 4. Exploratory Laparotomy

Figure 5. 5A. Complex Penetrating Liver Injury AAST Grade III-V; 5B. Combined Open and Endovascular Liver Isolation with Pringle Maneuver, REBOA (resuscitative endovascular balloon occlusion of the aorta) and REBOVC (Resuscitative balloon occlusion of the inferior vena cava)

Figure 6. Cross-Clamping of the Descending Thoracic Aorta

Figura 1. Redistribución sanguínea luego de la colocación de REBOA en Zona 1

Figura 2. 2A.Esternotomía mediana con extensión supraclavicular o cervicotomía longitudinal derecha para manejo de lesiones torácicas centrales; 2B. Esternotomía mediana con extensión supraclavicular o cervicotomía longitudinal izquierda para manejo de lesiones torácicas centrales.

Figura 3. Toracotomía anterolateral izquierda con incisión en Clamshell

Figura 4. Laparotomía exploratoria para lesiones abdominales

Figura 5. 5A.Lesiones hepaticas complejas grado III-V de la AAST; 5B. Aislamiento hepático combinado endovascular y abierto con maniobra de Pringle, REBOA (Oclusión con balón endovascular de reanimación de la aorta) y REBOVC (Oclusión con balón de reanimación de la vena cava inferior)

Figura 6. Clampeo externo de la aorta torácica descendente